Provider Demographics
NPI:1366084824
Name:JOHNSON, NIKITA KENYETTA (CPM-S, CST-OB, PCT,)
Entity type:Individual
Prefix:
First Name:NIKITA
Middle Name:KENYETTA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CPM-S, CST-OB, PCT,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8407 MAIN ST STE 3A
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-4867
Mailing Address - Country:US
Mailing Address - Phone:443-570-5414
Mailing Address - Fax:
Practice Address - Street 1:8407 MAIN ST STE 3A
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-4867
Practice Address - Country:US
Practice Address - Phone:443-570-5414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-16
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374J00000XNursing Service Related ProvidersDoulaGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD000000000000000000Medicaid
MD000000000000000000OtherNURSING SERVICE RELATED PROVIDERS TYPE